http://www.cfha.net/forum_thread.php?t=56Recent posts in Larry Mauksch: "Using Direct Observation for Team Development and Collaborative Training"http://www.cfha.net/forum_thread.php?t=56#post83pRegarding direct observation from anbsptraining perspective this is an area where the medical and mental health fields seem to take a different approach.nbsp Mental health training programs particularly MFT schools put a premium on livenbspor video-taped supervision.nbsp Medical training puts a premium on precepting and rounding and a see one do one teach one approach.nbsp Faculty physicians are very accessible to resident physicians but rarely during the patient interview itself.nbspppnbspppPerhaps due to these divergent traditions I find that some residents are more eager than others to engage in joint appointments live observation supervision and roleplays.nbspnbsp In contrast physicians seem more versed in thenbspmorning team huddle than counselors.ppnbspppYes I know I know cultural competency class teaches me not to speak in broad terms about classes of people please pardon my stereotyping unless you agree.phttp://www.cfha.net/forum_thread.php?t=56#post80pGreat postnbsp Im pretty sure I can fit the word teamlets into a clinical discussion at least three times today.nbsp On a different notenbsp another measure we have used here at our clinic is to house the Behavioral Health Specialist in the same office room as the PCPs Ration 4 PCP1 BHS.nbsp It allows for a very busy and chaotic work space at times but it does facilitate not only the dissemination of general medicalpsychological knowledge but specific patient details as well.phttp://www.cfha.net/forum_thread.php?t=56#post78pI just love the term teamlets. Great post Larry I am going to have to figure out a way to begin to use teamlets more in my day to day professional vernacular.phttp://www.cfha.net/forum_thread.php?t=56#post77pI want to second Larrys important discussion.nbsp A few more thoughtsppnbspppFor new implementations of behavioral health in primary care everything the behavioral health clinician does while clinically very needed is likely to be administratively inconvenient.nbsp So two things need to happen 1. the BHC needs to make friends with everyone physicians midlevels nurses MAs reception and billing folks - everyone and 2. all of these folks need to have been in on the discussion of the coming implementation and be aware of its potential value to patients.nbsp Relationship development makes or breaks the implementation.nbsp This defines an important task for top administrators of the unit to be sure that 2 is done before the new faces shows up and an ongoing challenge to the new BHCs to keep 1 in the foreground of their attention even as the clinical work gets faster and more complex.ppnbspppSome folks can keep the importance of team members in their consciousness as they see patients but many cant.nbsp To get people working in teams the interaction points need to be scheduled in not just waiting for the need to arise.nbsp Huddles as the start of a session which I think are crucial to teamwork and observations of each other will not happen spontaneously.nbsp They have to be part of the schedule.nbsp Teamwork occurrs in its enactment not in program design.phttp://www.cfha.net/forum_thread.php?t=56#post71pAn instant entry into the CBC opening lines hall-of-fame A great way to flounder or fail in system change... CLASSICphttp://www.cfha.net/forum_thread.php?t=56#post70pnbspA great way to flounder or fail in system change is to avoid relationship development between team members. When we examine efforts to integrate collaborative designs relationship development is often given short shrift or completely overlooked. For example the recently published initial evaluation results from the medical home National Demonstration Project found team function suffered Nutting et al Ann Fam Med 20097254-260.nbspnbsp One way to build teamwork is to use direct observation of day-to-day practice.nbspnbsp I have been experimenting with this strategy for 15 years and below I will share some experiences.ppnbsppp classMsoNormal stylemargin 0in 0in 10ptSince we began the mental health internship in collaborative care within our Family Medicine Residency in 1996 the first month for the new intern is spent shadowing residents and faculty. Observing helps the intern learn about the challenges of family practice and it spawns many new relationships. Our residents and medical students observe one another regularly as well.pp classMsoNormal stylemargin 0in 0in 10ptIn 1998 I was invited to spend a year training providers serving patients and designing a system of care in an indigent primary care clinic. During the first half of the year I regularly observed the primary care providers teaching them interview and primary care psychotherapy skills and forming relationships. My behavioral health practice grew rapidly. A few years before I arrived a local agency had placed a counselor in the clinic.nbsp Six months later the counselor was withdrawn due to lack of referrals despite being in a clinic where 50 of the patients had one or more mental disorders.nbsp Looking back it appears that little was done to create relationships with this new team member.pp classMsoNormal stylemargin 0in 0in 10ptIn my work with health care organizations to train primary care teams to be more efficient and effective in communication with patients a standard portion of training is peer observation. When the lack of team coordination between medical assistants and physicians became a common theme I began asking physicians how often they had observed their medical assistants or if medical assistants had observed them. The answer was almost always the samemdashteam observation had never occurred. I began having these dyads observe one another and discuss how to increase the quality and efficiency of patient flow. These primary care dyads or ldquoteamletsrdquo see Bodenheimer Ann Fam Med 2007 5547-461 immediately began dissecting day-to-day processes to improve systems of care.pp classMsoNormal stylemargin 0in 0in 10ptCollaboration is hard won without adequate relationship development.nbsp One way of forming relationships is to curiously watch each other provide patient care.nbsp It takes time.nbsp Trainees need to be sensitive to how feedback is delivered and remember that watching someone else promotes observation of onersquos self.pp classMsoNormal stylemargin 0in 0in 10ptMany of you have other strategies to promote team development or perhaps use similar approaches. What experiences have you had where team development went really well or stumbledp